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The Magic Camp
Making intervention fun
Dido Green
Professor in Occupational Therapy
11th October 2019, Stockholm
Bimanual skills – in everyday life
Manual Skills in Unilateral Cerebral Palsy (UCP)
Evidence Based Interventions show
benefits from intensive interventions of 60
to 12 hours
6 hrs/day//2 wks to 2 hrs/day/8 weeks
How to deliver this?
What makes the difference in outcome?
How do neurological mechanisms
underpinning these difficulties influence
outcomes?
from www.breatheahr.org
Neuroplasticity reflects the brain's capacity to change
and adapt across the life span.
Structures within the brain may work differently or with
different connections arising between structures.
• Changes in Activation / Activation patterns
• Changes in Connectivity
• Relationship of neuroplastic changes to functional
changes.
Constraint Induced Movement Therapy
Hand-Arm Bimanual Intensive Therapy (HABIT)
Evidenced Based Motor Interventions
Camp: n=10 children per camp (max)
10 days over 2 weeks x 6 hours per day = 60 hrs
Staffing ratio: avg. 2 adults for 3 children
Morning: learning bimanual magic hand tricks
Afternoon: making costumes/equipment for Magic Show
Final Day = Magic Show
(Magic-themed) Intervention (Green et al, 2013)
Bimanual tasks
Chopping vegetables for breakfast/lunch
Making costumes for magic show
Recruitment by
neurologists
MRI scan
(T1, T2,
fMRI, DTI)Post
Interventio
n
and follow
up motor
assessment
Baseline motor assessment
2 week
Magic camp
HABIT intervention
Magic Camps
Israeli camp
2010 N=9
UK camp 2012 n=6,
2014 n=6
MRI
scan
Baseline motor assessment
Israeli camp 2011N=9 Magic camp
N=4 individual
Post
Intervention
MRI scan2 week
Magic camp
HABIT intervention
Post
Intervention
motor
assessment
Month
follow-up
motor
assessment
Month
follow-up
MRI scan
Home
intervention
Study : Setup
0
100
200
300
400
500
600
700
Initial Pre-Camp
IL
UK2
0
100
200
300
400
500
600
700
Pre-camp Post-camp 3-mfu
JTTH
F To
tal S
peed
(sec
s) A
ffect
ed H
and
IL
UK1
UK2
a) Natural progress, Bimanual b) Natural progress, Unimanual
c) Intervention effects, Bimanual d) Intervention effects, Unimanual
Reprinted from Green et al., 2013 Developmental Medicine Child Neurology
Results: Bimanual and Unimanual Skills
• WM integrity at the affected PLIC correlated with all hand motor function assessments.
• WM integrity at the CC was significantly correlated with performance on the AHA, JTTHF and CHEQ of both the affected and less affected hands
Better connectivity of affected motor tract-> better hand function& some children showing pathways from non-affected hemisphere to affected hand.
Better connectivity in the Corpus Callosum ->
better hand function
➢ fMRI showed negative correlations between contralesional brain activation
when moving the affected hand and AHA improvements (T2: r = –.562,
T3: r = –0.479).
➢ FA in the affected PLIC correlated negatively with increased bimanual use on
CHEQ at T2 (r = –547) and AHA at T3 (r = –.656).
Pre – Post Treatment EN 7 y L hemi+ Brain change + functional improvement.
• Contrast Maps: R hand vs. baseline
• (less Affected)After (red)- before (blue)
Contrast Maps: L hand vs. baseline
(Affected) After (red)- before (blue)
Some increase activation post-intervention for the affected left hand in the right motor sulcus,
Much greater increase seen at the month follow-up.
Increased activation in the left motor sulcus when moving the right hand at follow-up.
Also increase in passive betas at month follow-up on both sides.
Changes correspond to improvement post-treatment & FU on the Jebsen (unimanual skills)
“ “ to improvement at month follow-up on the AHA (bimanual skills)
“They won’t sit
next to me (at
school) as they
don’t want to catch
my disease!”
“Games at school – they
always chose me last and
then the other side gloats
when they win.”
About new Friends
…” P (older boy)
because he’s grown
up and he’s OK”
I am a one handed
boy – I don’t want to
be associated with
‘them’.
What do the children say? Are we listening?
• Psychosocial factors may influence development of movement
efficacy in children with Unilateral Cerebral Palsy (Curtain &
Clarke 2005,Gilmore etal 2010, Skold etal 2007, Green et al 2013).
• Up to 61% of children with UCP may have persistent mental
health problems affecting perceptions of confidence, competence
and positivity (Goodman & Graham 1996; Parkes et al 2008).
• Therapeutic outcomes from interventions for children with UCP are
influenced by children’s engagement which may be linked to
mastery motivation (Miller et al, 2014).
• Yet few studies investigate psychosocial factors underpinning the
experiences of children and influence on engagement and therapy
outcomes.
Background
A Qualitative study to:
▪ Explore the expectations and experiences of children with UCP participating in a 60 hour day-camp using a magic-themed bimanual intensive therapy
▪ Semi-structured interviews before & after camp with children & parents.Interviews analysed with NVivo
© Breathe Arts Health Research
Exploration of Experiences of Therapy
Characteristics of participants (n=15) UK summer camp
Age Child: Median (range)8 years (7 years - 11years 11 months)
Gender Child: males/females 11/4
Gross Motor Classification System Level I n= 13 / II n=2 Manual Ability Classification System Level I n=4 / II n= 6 / III n= 5
Pre-camp interviews Child (n=15); Parent (n=13)
Post-camp interviews Child (n=14); Parent (n=15)
Characteristics of participants
Grounded Theory & Thematic Analysis:
to identify, examine and record topics (themes) occurring
within the data relating to experience of having a disability,
exposure to therapy and expectations for intervention.
▪ Familiarisation with the data in the transcripts
▪ Generation of initial codes
▪ Themes coded to establish meaningful patterns
▪ Review of themes
▪ Defining and naming themes
Nvivo 10 was used to identify frequencies, co-occurrence and
emphasis, and display relationships between different themes
© Breathe Arts Health Research
Interviews Methods & Analysis
Perceptions of Therapy
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Researcher:Can you tell me how you feel (like/dislike) having to do these exercises?
7 year old boyAnnoying I have to do them every time and XXX watches and whatever stretches and things and annoying I have to go outside of the class with three others every day. Annoying – lasting for a months, I hate physioToo much Yea – four months 12 months we have to do them for months for 12 months very annoying (again animated)every year every year. I might not have any exercises (new school)
Thematic extraction identified four main
themes relating to:
1. Self-concept
2. Achievement Behaviour
3. Socialisation
4. Perceptions of therapy
Pre Intervention Theme 1 – Self Concept
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▪Children were reluctant to talk about what it is like to have
a hemiplegia (n= 8 no answer) Others provided very limited
responses
▪Many children (n=8) and parents (n=7) used negative
terms reflecting annoyance, frustration or negative
comparisons, with a desire for the affected hand to be like
the other hand.
▪A lack of confidence in using the weaker hand was reported
from many children (n=8) and parents (n=10).
Post Intervention Theme 1 – Self Concept
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▪Children reported increased confidence in using
their helper (affected) hand (n=5).
▪Parents (n=5) commented that children seemed
more intrinsically motivated to use their helper
hand in everyday activities
▪Children (n=7) and parents (n=9) reported on the
benefits of the camp for friendships and
confidence.
What do the children say before?
Experiences and Self-concept
A bit weird, Because I
I’d sit with them at
lunch time and play
with them and do lots
of magic tricks and
have fun and all that
kind of stuff.
Annoying, I have to
do them (exercises)
every time and ,….
The right hand’s got
all the goodness in it
and all the strongness
in it but this hand
hasn’t really
(any)thing in it
Pre Intervention Theme 2 – Socialisation
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▪Children’s responses (n=12) reflected social awkwardness
with a lack of elaboration on questions related to activities
undertaken with friends or no description of what they do
together and no friends were named.
▪Parents’ responses (n=9) reflected more pronounced social
difficulties: difficulties forming friendships, difficulties
mixing with others, not able to do the same things as peers,
or commenting the child only did activities when with
cousins or family members.
Post Intervention Theme 1 – Socialisation
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▪Children commented on new friends and the value
of certain activities particularly the play after lunch
▪Few children mentioned specific friends they had
made on the camp
▪For some children it was their first experience of
being with ‘similar others’.
What do the children say after?
Socialisation and self-concept
❖Umm I just ignore
it. I don’t really feel
bad about it.
I like being different, so I
like having hemiplegia,
because you’re different,
you’re not the same.
You’re different in your
own way*
… but then do a bit of practising and
will get better probably (so it will get
better you think with practice
Thank you for pushing us,
Thank you for not giving up
on us.
Thank you for not feeling
sorry for us.
What are Clinically Meaningful Outcomes?
“Now that I can
carry my own tray, I
am no longer last. I
can start the games
and conversations
after lunch”
“My hand is feeling
much better now
and the hemiplegia
is coming away!”
Thank you for
turning my disability
into an ability
© Breathe Arts Health Research
Celebrate Success
Marnie Kimelman TrustElizabeth Casson
Trust
Maya Weinstein, Dr Mitchell Schertz, Dr Shelly Shiran, Vicky Myers, Moran Artzi, Dr Lian Ben-Sira, Dr Ronni Geva,Dr Varda Gross-Tsur,
Dr. Dafna Ben Bashat, Dr. Aviva Fattal-ValevskiDr Verity McClelland,Dr Gareth Barker,Dr Geoff Charles-Edwards,Dr Andrew GordonBecca Krom
Julian Rudisch, Dr Deidre Birtles, Prof. Bert Steenbergen, Dr Maritje Jongsma, Ingar Zielinski, Dr Pauline Aarts
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